- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $1,513.56 / $2,089.30
| Facility | | $741.31 | $1,513.56 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $660.69 / $794.33
| Professional | | $630.96 | $660.69 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $1,258.93
| Facility | | $676.08 | $676.08 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $3,548.13
| Professional | | $676.08 | $676.08 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,000.00 / $5,011.87
| Facility | | $812.83 | $1,000.00 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $794.33
| Professional | | $660.69 | $660.69 | $794.33 |